Complete the Performance Improvement Tool Worksheet*

Use this checklist to evaluate your current practices with patients who have ITP. This can be used to review specific cases, or as a guide to think about your approach to thrombocytopenia. In what ways have your experiences with ITP influenced your management of thrombocytopenia, and how have recent advances changed your diagnosis and treatment paradigms?
*This sheet must be completed in order to obtain additional credits.

All fields required

 
Platelet count at presentation (x 109/L)

  
> 150
100–150
50–100
20–50
< 20
 

 
History of bleeding?

  
Patient 
Yes   No  
 
1st degree relatives 
Yes   No  
 
Extended family 
Yes   No
 

 
Is there a known cause of thrombocytopenia?

  
Recent surgery or procedure  
Glycoprotein IIB-IIIA inhibitors  
Antibiotics  
Sepsis  
HIV infection  
HCV infection  
H pylori infection  
Cirrhosis or portal hypertension with splenomegaly  
HIT  
MDS  
Chemotherapy  
Treatment of liver disorder‚ eg‚ interferon  
Autoimmune disorder‚ eg‚ SLE‚ Evans Syndrome  
TTP/HUS  
Leukemia  
None known
 

 
Evidence of blood disorder

  
Bleeding  
Thrombosis  
Anemia  
GI bleeding  
Petechiae  
Ecchymoses  
Bleeding gums  
Epistaxis  
Menometrorrhagia  
Other
 

 
Blood tests

  
CBC 
Normal   Thrombocytopenia   Other  
 
Smear 
Normal   Thrombocytopenia   Other  
 
HCT 
Normal   Anemic  
 
Reticulocyte count 
Normal   Increased
 

 
Suspicion of infection?

  
HCV  
HIV  
H pylori  
CMV  
Other
 

 
Suspicion of hypogammaglobulinemia?

  
Yes   No
 

 
Suspicion of abnormal thyroid?

  
Yes   No
 

 
Suspicion of concurrent hemolysis?

  
Yes   No
 

 
Was a bone marrow aspirate and/or biopsy performed?

 
Yes   No
 

 
Was there a hematology consult?

  
Yes   No
 

 
Does the thrombocytopenia respond to

  
Steroids 
Yes   No   Not used  
 
Pulsed dexamethasone 
Yes   No   Not used  
 
IVIG 
Yes   No   Not used  
 
Anti-D 
Yes   No   Not used  
 
Rituximab 
Yes   No   Not used  
 
Eltrombopag 
Yes   No   Not used  
 
Romiplostim 
Yes   No   Not used  
 
Immunosuppressants 
Yes   No   Not used  
 
Danazol 
Yes   No   Not used  
 
Other (specify) 

 

 
Splenectomy

  
Is a splenectomy indicated? 
Yes   No  
 
Pneumovax - vaccination current? 
Yes   No  
 
H influenza - vaccination current? 
Yes   No  
 
N meningitidis - vaccination current? 
Yes   No  
 
Was a splenectomy performed? 
Yes   No  
 
Did the thrombocytopenia respond? 
Yes   No
 

 
What was the outcome?

  
Uneventful resolution of thrombocytopenia
Persistent thrombocytopenia
No symptoms
Bruising
Petechiae
Bleeding gums
 

 
Did this analysis influence your subsequent patient management?

 
Yes No
 

 
Did this analysis influence your workplace practices?

 
Yes No